2. Main objectives of treatment
• The main objectives in treating naso-orbital-
ethmoid (NOE) fractures include management
of the medial canthal tendon to restore the
intercanthal distance, restoration of collapsed
nasal projection and orbital volumes
3. objectives
• The objectives in treating these injuries
include restoration of dorsal nasal height;
orbital rim contours; orbital volume; and
importantly, the intercanthal distance
4. Markowitz classification
• Type I fractures have a single central fragment
with an attached tendon
• Type II fractures have a comminuted central
segment with the tendon remaining attached
to a solid piece of smaller bone.
• Type III fractures have a comminuted central
segment and a detached tendon
5. Treatment strategies
• Current treatment strategies include
1)conservative or closed management if there
is minimal displacement of the bones involved
2) if there is significant displacement of bones,
detachment of the medial canthal tendon, loss
of nasal dorsal height, or an increase in orbital
volume open exploration with internal fixation
is indicated
6. Surgical Approach
• The most widely used approach for complex
NOE fractures is the coronal flap combined
with lower lid or transconjunctival and
maxillary vestibular incisions
7. Surgical Approach
• Type I fractures may be accessed via a
maxillary vestibular incision alone.
• However, type II and III fractures must be
accessed via a coronal flap or through existing
lacerations
8. Coronal approach
• The coronal flap may be elevated in the
subgaleal plane until about 2.5 cm superior to
the orbital rims.
• At this point, the periosteum should be
incised and elevated to expose the frontal
bone, nasal bones, and medial orbits.
9. Surgical procedure
• Identify the medial canthal bearing bone and
medial canthal tendon
• Reconstruction of the medial orbital rim and
then the internal orbit as needed
• Resuspending the medial canthal tendon
• Reducing the nasal septum
• Reconstruction of the nasal dorsum and bone
grafting
• Managing soft tissue
